image by: James Heilman, MD

HWN Suggests

Bowel Perforation: ED presentations, evaluation, and management

Beware of bowel perforation mimics on CT scan, including postoperative pneumoperitoneum. Post-operative patients can also be at risk of perforation and pose challenges in delineating expected post-operative air versus perforation. In these cases, clinical correlation with the patient’s symptoms and vital signs and early surgical consultation is recommended.

Remember to optimize medical management before the OR, including giving fluid resuscitation and antibiotics to cover Gram negative and anaerobic bacteria. Choices include piperacillin-tazobactam or a carbapenem (i.e. meropenem), though lower risk patients can still be covered by the combination of ceftriaxone and metronidazole.

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 Ultrasound For The Win! – 46M with Diffuse Abdominal Pain #US4TW

The major pitfall when looking for pneumoperitoneum with ultrasound is misinterpreting intraluminal air (i.e. normal air within the bowel) as extraluminal air (i.e. abnormal air outside of the bowel). One way to avoid this is to scan your patient at the right upper quadrant, where there is an absence of bowel. Use of the ‘shifting phenomenon’ described previously may also aid in avoiding this pitfall.

Articles of Interest

Diverticulitis: Outpouchings of Doom

Diverticulitis can be either complicated or uncomplicated. It is deemed complicated when there is either perforation or abscess formation.

Gastrointestinal Perforation

The main feature of gastrointestinal perforation is pain. Typically this is rapid onset and sharp in nature. Patients are systemically unwell and may also have associated malaise, vomiting, and lethargy.

Gastrointestinal Perforation and the Acute Abdomen

Suspected gastrointestinal perforation should be excluded in patients who have an acute abdomen. Although the term ‘‘acute abdomen’’ sometimes refers to conditions requiring urgent surgery, the term most often refers to any patient who develops abdominal pain over a relatively short time interval.

Pneumoperitoneum

In the absence of free fluid, pneumoperitoneum can be challenging to identify, as it is difficult to distinguish normal air within the intestines from pathologic free air. Free air will appear as ringdown or reverberation artifacts. It is typically best image over the ventral surface of the liver.

Resources

StatPearls

Bowel perforations can be separated based on their anatomic locations, but many causes are overlapping.

WikEM

Typically presents acutely (i.e., appendicitis, diverticulitis, perforated peptic ulcer, penetrating trauma) and often requires immediate surgical intervention.

WikiDoc

Treatment depends on the underlying cause, but surgical intervention is nearly always required.